Provider Demographics
NPI:1154689685
Name:HARTKE, JUSTIN GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GABRIEL
Last Name:HARTKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4152
Mailing Address - Country:US
Mailing Address - Phone:715-847-2558
Mailing Address - Fax:715-847-2557
Practice Address - Street 1:411 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-847-2558
Practice Address - Fax:715-847-2557
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69359-20207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program